Post Colectomy Ileitis in patients with Ulcerative Colitis: A Diagnostic Challenge

Post-operative ileitis following total colectomy is an uncommon yet serious condition. This represents a diagnostic challenge and often the original pathology of the infl ammatory bowel disease should be revisited. Initial cases of postcolectomy ileitis were reported over 50 years ago. Since then it has been described to exist in both acute (two to four weeks following surgery) and chronic (months to years post surgery) Abstract

Our second case is that of a 47 year-old male with UC who presented similarly acutely with severe abdominal pain and increasing stool frequency. He was treated with intravenous Hydrocortisone but despite this, he continued to deteriorate clinically. He subsequently underwent to a subtotal colectomy with end ileostomy, histology confi rming UC. The patient was discharged 15 days after surgery on a reducing regimen of steroids. The patient presented four weeks later to the emergency department with severe abdominal pain and raised infl ammatory markers. The patient represented a second time with worsening abdominal pain, high output stoma and faeculant discharge from the side of the stoma. He was taken to theatre for a re-laparotomy, and perforation was found at the side of the terminal ileum, which was also thickened and dusky in appearance with multiple mucosal ulcerations. Histology showed mild chronic active infl ammation with cryptitis. The ileostomy was re-fashioned and the patient was discharged nine days following his second laparotomy managing his stoma normally.
Our third case is a 45 year-old male who was initially

Differential diagnosis
The diagnosis of post-colectomy ileitis was made based on the clinical presentation of these patients along with the intraoperative fi ndings at laparotomy and the histological fi ndings of the resected small bowel. The differential of Crohn's disease (CD) was entertained, but histopathological features did not support this. Furthermore none of the patients in our small cohort developed small bowel strictures or fi stulae in our fi ve-year follow-up period.

Management
The diagnostic challenge under these circumstances

Discussion
There are few reported incidences of post-colectomy ileitis over the last 60 years [1][2][3][4][5][6][7][8]. The condition occurs following colectomy for UC, and can present either acutely within two to four weeks or chronically up to several years following the index procedure.
One group from The Cleveland Clinic has provided the bulk of published work on this subject [1,2] although the disease was fi rst described by Thayer and Spiro in 1962 [3]. The disease presents in one of two ways, either as an acute or chronic condition [1,4]. The chronic condition tends to occur over months to years of normal ileostomy function following the initial surgery usually presenting with diarrhoea, weight loss and stoma dysfunction. Stoma-related symptoms are secondary to chronic ulceration and subsequent fi brosis of the terminal ileum, stoma retraction, fi stula formation, chronic obstruction and dilatation [1].
Acute presentation has been reported within 10 to 14 days of the initial operation [1,9]. Fever, tachycardia and watery, often blood-stained stoma output were the predominant symptoms observed within this subgroup of patients. The authors reported that perforation occurred in 50% of the patients within this group and that these perforations were multiple and found on the anti-mesenteric border [1]. They have also reported that the extent of the disease process was diffi cult to determine because in their experience the external surface of the ileum "appeared relatively uninvolved". Parallels can clearly be drawn between the signs and   (RCT) with adequate long term follow up. One study has shown that a number of treatments used routinely for suppression of infl ammatory bowel disease (including 5-aminosalicylic acid and oral steroids) were ineffective in treating this condition [9], whilst other studies reported that Azathioprine was effective as it provided both symptomatic and endoscopic improvement [9,11]. However these fi ndings have only been reported in relatively small case series and also would be better assessed in a RCT setting.
Diffi culties in delivering effective treatment may stem from a lack of clarity regarding the underlying pathological process which drives post-colectomy ileitis. In many cases, the ileitis is a recurrence of the disease process for which the initial operation was done [1,9]. In others, the histology revealed a non-specifi c infl ammatory process [1], but this doesn't mean it is not the same original disease. A recent study with at least a 10-year follow-up period suggested that in up to 25% of patients undergoing colectomy for UC initially, the disease diagnosis was revised to be CD [12].
Post-colectomy ileitis is a commonly encountered condition that remains challenging in surgical practice. Its acute presentation can be fatal to the patient if not acted upon quickly. Better understanding of this condition would make it possible to diagnose sooner and hence commence earlier management and decrease associated morbidity. The paucity of available literature on the subject demands the need for management strategies to be formally investigated in the future in randomised trials.

Take home messages
-Post-colectomy ileitis should be considered a differential in UC patients post total colectomy who present with persistent abdominal symptoms.
-Although little is known about the underlying pathology, limited small bowel resection with TPN appears to be the mainstay of treatment.
-Reconsideration of the diagnosis of Crohn's disease should be undertaken with histological and radiological investigations.
-A multi-disciplinary approach in making the diagnosis and subsequent management is mandatory.